Vaccine xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Trends in diarrhea hospitalizations among infants at three hospitals

in Tanzania before and after rotavirus vaccine introduction
Faraja Lyamuya a, Fausta Michael b, Bhavin Jani c, Yohana Fungo b, Alfred Chambo d,1, Inviolatha Chami a,
Regina Bulali b, Amina Mpamba b, Happy Cholobi d, Dotto Kallovya e, Christopher Kamugisha c,
Jason M. Mwenda f, Margaret M. Cortese g,⇑
a
Dodoma Regional Referral Hospital, Dodoma, Tanzania
b
Mbeya Zonal Referral Hospital, Mbeya, Tanzania
c
World Health Organization, Country Office, Dar es Salaam, Tanzania
d
Mbalizi Hospital, Mbalizi, Tanzania
e
National Health Laboratory Quality Assurance Training Centre, Dar es Salaam, Tanzania
f
World Health Organization, AFRO Office, Brazzaville, Congo
g
Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: The Tanzania Ministry of Health introduced monovalent human rotavirus vaccine in January
Available online xxxx 2013, to be administered at ages 6 and 10 weeks. Data suggest there was high vaccine uptake. We used
hospital ward registers from 3 hospitals to examine trends in diarrhea hospitalizations among infants
Keywords: before and after vaccine introduction.
Rotavirus Methods: Ward registers from Dodoma Regional Referral Hospital (Central Tanzania), and two hospitals
Diarrhea in Mbeya (Southwest area), Mbeya Zonal Referral Hospital and Mbalizi Hospital, were used to tally
Gastroenteritis
admissions for diarrhea among children by age group, month and year. Rotavirus surveillance had started
Rotavirus vaccine
Infants
at these hospitals in early 2013; the proportion of infants enrolled and rotavirus-EIA positive were exam-
Disease burden ined by month to determine peak periods of rotavirus disease post-vaccine introduction.
Tanzania Results: Registers were available for 2–4 prevaccine years and 2–3 post introduction years. At Dodoma
Surveillance Regional Referral Hospital, compared with the mean of 2011 and 2012, diarrhea hospitalizations among
infants were 26% lower in 2015 and 58% lower in 2016. The diarrhea peak shifted later in the year first by
1 and then by 2–3 months from prevaccine. At the Mbeya hospitals, the number of diarrhea admissions in
prevaccine period varied substantially by year. At Mbeya Referral Hospital, diarrhea hospitalizations
among infants were lower by 25–37% in 2014 and 11–26% in 2015, while at Mbalizi Hospital, these
hospitalizations were 4% lower in 2014 and 14% higher in 2015. Rotavirus testing data demonstrated a
lowering of the prevaccine peak, a shift in timing of the peak months and indicated that other diarrheal
peaks in post-introduction years were not due to rotavirus.
Conclusions: In this ecological evaluation, total diarrhea hospitalizations among infants were lower
(25% lower in 1 year) following introduction in 2 of 3 hospitals. There are challenges in using ward
registers to ascertain possible impact of rotavirus vaccine introduction on trends in hospitalizations for
treatment of all diarrheal illness.
Published by Elsevier Ltd.

1. Introduction routine immunizations in the Expanded Programme on Immuniza-

The United Republic of Tanzania introduced monovalent rota-
virus vaccine, Rotarix, (GlaxoSmithKline, Rixensart, Belgium) in
January 2013, to be given at ages 6 and 10 weeks along with other
⇑ Corresponding author.
E-mail address: mcortese@cdc.gov (M.M. Cortese).
1
Deceased.
tions. Administrative data suggest that high coverage (96%) with
rotavirus vaccine was achieved (http://apps.who.int/immuniza-
tion_monitoring/globalsummary/estimates?c = TZA. Accessed 23
October 2017). An evaluation from Zanzibar, Tanzania indicated
the vaccine is effective in preventing hospitalization for rotavirus
disease in the country (effectiveness of 2 Rotarix doses among
children aged 5–23 months was 57%, 95% CI 14–78%) [1].

https://doi.org/10.1016/j.vaccine.2017.11.051
0264-410X/Published by Elsevier Ltd.

Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
2 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx
Rotavirus surveillance had been established before vaccine
introduction at 2 sites in mainland Tanzania and 1 site in Zanzibar,
and additional sites were established in 2013 [2]. We identified
that 3 of these mainland hospitals had register books available
for children who had been hospitalized with diarrhea during a per-
iod that encompassed at least 2 prevaccine years and 2 post-
vaccine years (not counting 2013, the year when vaccine was intro-
duced) and for whom a major change in hospital designation status
(e.g., change to a referral hospital) or estimated catchment popula-
tion (e.g., establishment of a new nearby hospital) had not
occurred during that timeframe. We used these registers to exam-
ine trends in diarrhea hospitalizations among young children at
these sites following vaccine introduction, with a focus on infants.
2. Materials and methods
One hospital was in Dodoma region (Central Tanzania) and two
were in Mbeya region, in the Southwest area.
The Dodoma Regional Referral Hospital is located in Central
Tanzania within Dodoma Municipality. It is a Level II referral hos-
pital and also serves patients who come directly from home with-
out referral. It is the only hospital in Dodoma municipality that
provides care for children aged <5 years free of charge. Mbeya
Referral Hospital is a tertiary care hospital for the Southern High-
lands Region of Tanzania, which also serves children aged <5 years
who come from the catchment area without referral. Mbalizi
Hospital is located 20 km east of the city of Mbeya, and is run as
a collaboration between Mbalizi Evangelistic Church and the Min-
istry of Health and Social Welfare of Tanzania, as a District Desig-
nated Hospital. It serves the surrounding peri-urban and rural
areas of the district.
At each of these hospitals, children hospitalized with diarrhea
are managed in a specific location, in part to help prevent nosoco-
mial transmission by cohorting. (At Mbeya Referral Hospital,
infants aged <28 days were rarely admitted to this ward, whereas
at the other two hospitals, such infants were admitted to the wards
providing the data). Each hospital had a ward register that included
these fields of interest: date of admission, child’s age (usually age
in months if age <1 year, then age in years), an initial/admission
diagnosis (es), and a final diagnosis (es). Date of birth was not
included. For each calendar month, we tallied the number of chil-
dren admitted by age group (age <1 year and by categories of age
in months, 1 year, 2 years, 3–4 years) whose diagnosis included
diarrhea or gastroenteritis as the first or second term listed. At
the Dodoma hospital, we tallied based on the initial diagnosis
because the ward (and its register) also included children hospital-
ized for illnesses other than diarrhea and we wanted to avoid
including possible nosocomial diarrheal illness. At the Mbeya hos-
pitals, we used the discharge diagnosis because this appeared to be
more specific. We did not include children whose diagnosis
included dysentery, bloody diarrhea, food poisoning, or chronic
diarrhea. For each hospital, we compared the numbers of diarrhea
hospitalizations in each of the post-introduction years with the
median of the prevaccine years and focused on infants aged
<1 year.
Procedures were modified in two situations. In late 2014, the
Mbeya Referral Hospital began implementing an electronic register
for pediatric patients, in addition to maintaining the written regis-
ter for the ward. In early 2015, the written register was maintained
by the clinical staff but, given staffing changes, there was possibil-
ity that it may not have continued to capture all admissions. There-
fore, in order to better ensure we captured all of the admissions in
the tallies, we used the written ward register as well as a separate
diarrhea admission line list and enrollment data collected as part
Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
of the rotavirus surveillance system. (Data from the roll-out of
the electronic system were not available for our purposes).
In late 2015, a cholera outbreak began in Dodoma as well as in
other regions of Tanzania; the Mbeya area was not affected. The
outbreak in Dodoma during October 2015–April 2016 occurred in
the catchment area served by the Dodoma Regional Referral Hospi-
tal. Cholera treatment centers (CTCs) were established in that area
to manage patients with suspected cholera. Because it was possible
some children with severe diarrhea that was not caused by cholera
may have been managed at CTCs, we reviewed the data from the
CTCs and tallied those children who resided in the hospital catch-
ment area and were either not tested for cholera or who were test-
negative. These children were then included in our tallies as if they
had been hospitalized at Dodoma Hospital.
Rotavirus-specific data from these hospitals were available
only for the post-introduction period. In March-April 2013, rota-
virus surveillance was started at these 3 hospitals and was
focused on enrolling children who would have been eligible to
have received rotavirus vaccine based on date of birth (i.e., born
01 November 2012). For the first few months of surveillance,
however, some children who were born before this date were
also enrolled and tested. As detailed elsewhere [2,3], children
admitted to the hospital because of acute diarrhea had a stool
sample obtained and tested for rotavirus by enzyme immunoas-
say (EIA) and demographic and other information were obtained.
To estimate the total number of infants hospitalized with rota-
virus diarrhea during each month that surveillance was con-
ducted, for each month we determined the proportion of
infants enrolled that were rotavirus-positive and applied this
proportion to the total number of infants hospitalized with diar-
rhea that month based on the tallies from the ward register. The
remaining were considered rotavirus-negative. At Mbalizi, 2
infants had rotavirus EIA results for 2 months in 2014 and 3
months in 2015; more infants had results from Mbeya Referral
Hospital, so rotavirus positivity rates from the referral hospital
were used in the Mbalizi estimates for those specific months.
In each calendar month in 2014 and later, infants aged 6 weeks
through 11 months at the time of diarrhea hospitalization would
have been eligible to have received at least one dose of rotavirus
vaccine prior to admission, based on the roll-out of vaccine in Jan-
uary 2013. Similarly, in each calendar month of 2015 and later,
children aged 12–23 months at the time of hospitalization would
have been eligible to have received vaccine during infancy.
3. Results
At Dodoma Hospital, data were available for two prevaccine
years (2011 and 2012) and 3 full post-vaccine introduction years
(2014–2016). The number of diarrhea hospitalizations and timing
and shape of the diarrhea hospitalization curve among infants
was similar for the two prevaccine years (Table 1, Fig. 1). Beginning
in 2013, the peak number of diarrhea hospitalizations occurred
later in the year, shifting first by 1 and then by
2–3 months from prevaccine (Fig. 1).
Compared with the prevaccine median (n = 255), the number of
infants hospitalized for diarrhea was 34%, 9%, 26% and 58% lower in
2013, 2014, 2015 and 2016 respectively. (1 infant and 29 children
aged 1–4 years from the hospital catchment area had been hospi-
talized at the CTC for suspected cholera during 2015–6 and were
incorporated into the respective month counts of diarrhea
hospitalizations).
The estimates (adjusted numbers) of the total rotavirus positive
hospitalizations for infants in 2015 was half that of 2014, while the
estimates for rotavirus negative hospitalizations were the same;
numbers were lower in 2016 for both categories but a relatively
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-

Table 1
Diarrhea hospitalizations among children aged <5 years, by age group, before and after rotavirus vaccine introduction. (Vaccine introduced January 2013).

Prevaccine Post vaccine introduction

2009 2010 2011 2012 Median 2013 2014 2015 2016
Hosp,n Hosp,n Hosp,n Hosp,n Hosp,n Hosp,n Reduction in hosps, Hosp,n Reduction in hosps, Hosp,n Reduction in hosps, Hosp,n Reduction in hosps,
n (% reduction)a n (% reduction)a n (% reduction)a n (% reduction)a
Dodoma Regional Referral Hospital
Age < 1 y – – 249 261 255 169 86 (34) 231 24 (9) 189 66 (26) 108 147 (58)
Rota posb 66–115 91 45 26
b
Rota neg 54–103 140 144 82
Age 1 y – – 117 132 124 116 8 (7) 161 36 ( 29) 142 18 ( 14) 95 30 (24)

F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx

Age 2–4 y – – 57 49 53 41 12 (23) 49 4 (8) 72 19 ( 36) 64 11 ( 21)
Total < 5y – – 423 442 432 326 106 (25) 441 8 ( 2) 403 30 (7) 267 165 (38)
Mbeya Referral Hospital
Age < 1 y 622 485 349 227 417 346 71 (17) 261 156 (37)c 307 110 (26)c –
Rota posb 113–146 56 85
Rota negb 200–233 205 222
Age 1 y 314 252 219 218 236 332 96 ( 41) 201 34 (15)c 198 38 (16)c –
Age 2–4 y 110 99 83 79 91 101 10 ( 11) 109 18 ( 20)c 74 17 (19)c –
Total < 5y 1046 836 651 524 744 779 36 ( 5) 571 172 (23)c 579 164 (22)c –
Mbalizi Hospital
Age < 1 y – 276 346 450 346 394 48 ( 14) 333 13 (4) 395 49 ( 14) –
Rota posb 107–145 98 144
Rota negb 249–287 235 251
Age 1 y – 174 183 251 183 254 71 ( 39) 220 37 ( 20) 202 19 ( 10) –
Age 2–4 y – 67 66 82 67 112 45 ( 67) 92 25 ( 37) 67 0 (0) –
Total < 5y – 517 595 783 595 760 165 ( 28) 645 50 ( 8) 664 69 ( 12) –

– = Not available. y, years.

Bolded values are the prevaccine median number of diarrhea hospitalizations among children aged <1 y and age <5 y, and reduction in diarrhea hospitalizations (n, %) for each post-vaccine year.
a
Compared with prevaccine median. Negative number in post-vaccine year indicates increase compared with prevaccine.
b
Estimates by applying proportion of infants tested that were rotavirus positive (vs negative) to total number of infants admitted for diarrhea in the respective month. Range for 2013 indicates that there were months in 2013
without information on rotavirus positivity among infants (total diarrhea hospitalizations among infants for those months were: Dodoma (January, February, March, June) n = 49; Mbeya Referral (January, February), n = 33; Mbalizi
(January, February), n = 38).
c
Compared with the 2011–2013 median (n = 346, 219, 83 and 651 in ages <1, 1, 2–4 and <5 years), hospitalizations in 2014 and 2015, respectively, were lower by 85 (25%) and 39 (11%) among infants; 18 (8%) and 21 (10%)
among those aged 1 year, 26 ( 31%) and 9 (11%) among those 2–4 years, and total of 80 (12%) and 72 (11%) for <5 years.

3
4 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx

Fig. 1. Dodoma Regional Referral Hospital. Panel A. Number of diarrheal hospitalizations among infants by month. Panel B. Proportion of infants enrolled in surveillance that
were rotavirus-positive, by month. Rotavirus results were not available for months with no columns. Panel C. Number of diarrhea hospitalizations among infants by month.
Pre-April 2013: Grey columns indicate total diarrhea hospitalizations. April 2013 onward: blue section of column represents adjusted number that were rotavirus-positive;
grey section represents adjusted number that were rotavirus-negative. Hashed columns indicate total diarrhea hospitalizations for months with no rotavirus testing result
available.

Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx 5

Fig. 2. Mbeya Referral Hospital. For simplicity, data for 2009, 2012, 2013 are not presented in Panels A and B of this figure but are presented in Supplemental Fig. 2.

larger reduction was observed in the rotavirus-positives (Table 1,
Supplemental Fig. 1).
At Mbeya Referral Hospital, data were obtained from 2009
through 2015. During the first 4 years, the total number of diarrhea
hospitalizations among children aged <5 years was lower each
subsequent year until 2013, when the hospitalizations (n = 779)
were higher than both 2012 (n = 524) and 2011 (n = 651) (Table 1).
A decrease in the number of diarrhea hospitalizations among
infants was also noted through 2012, but hospitalizations in
2013 (n = 346) were greater than in 2012 (n = 227) and virtually
the same as in 2011. Compared with the overall prevaccine median
(n = 417), hospitalizations among infants in 2014 (n = 261) and
2015 (n = 307) were 37% and 26% lower, respectively. In a conser-
vative analysis, with the more proximal years of 2011–2013 con-
sidered the comparison (median = 346), hospitalizations among
infants were 25% and 11% lower in 2014 and 2015, respectively.

Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
6 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx

Fig. 3. Mbalizi Hospital. *in Panel B indicates calendar months when rotavirus positivity rate from Mbeya Referral Hospital was used.

Within the individual prevaccine years at Mbeya Referral tal Fig. 2). During the later years, a predominant peak month was
Hospital, there was a notable peak month of infant diarrhea hospi- not observed. Based on the surveillance testing, the months with
talizations only in 2009 (June) and 2011 (July) (Fig. 2, Supplemen- the higher number of rotavirus cases in 2013 were June through

Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx
August, and in 2015 in July through September (Fig. 2). The results
suggested that the rotavirus hospitalizations among infants in
2014 were notably lower than in 2013, and more clustered than
in 2013 or 2015 (Fig. 2, Supplemental Fig. 3).
Although in the same region, the data on total diarrhea hospital-
izations from Mbalizi Hospital were different from those of Mbeya
Referral. At Mbalizi, the prevaccine counts were higher each succes-
sive year with 2012 having the highest total (rather than the lowest,
as at Mbeya Referral) (Table 1, Fig. 3). At Mbalizi, counts among
infants in 2014 were only slightly (4%) lower than the prevaccine
median and in 2015, were higher than prevaccine median ( 14%).
Similar to Mbeya Referral, Mbalizi 2011 peak numbers occurred in
June and July, and one marked peak was not observed in 2010.
Rotavirus cases at Mbalizi also appeared more tightly clustered in
2014 than 2013 or 2015, with a shifting in peak numbers to later
in the calendar year over these years (Fig. 3, Supplemental Fig. 2).
4. Discussion
The data from 2 hospitals (Dodoma Regional Referral Hospital,
Mbeya Referral Hospital) in different regions of Tanzania indicate
that diarrhea hospitalizations among infants were lower (25%
lower in 1 year) after rotavirus vaccine introduction compared
with the median of the prevaccine period. A reduction was not
detected at a third hospital (Mbalizi Hospital, also in Mbeya
region). While there are no definitive explanations for the findings
at the third hospital, it is perhaps not surprising that there was
variation in the findings given the challenges and limitations with
using hospital ward register counts over time, and ecologic analy-
ses in general.
The strongest data supporting a conclusion that rotavirus
vaccine introduction lowered the burden of hospitalization for
diarrhea among infants comes from Dodoma Hospital. The shifting
of the notable peak number of diarrhea hospitalizations to later in
the year has been observed in several locations [1,4–7]. Rotavirus
testing data from 2011 to 2012 at 2 hospitals in other mainland
Tanzania locations (Mwanza and Tanga, Supplemental Fig. 3) sup-
port that rotavirus was a major contributor to the Dodoma peak in
those years. The rotavirus testing data at Dodoma combined with
the total monthly diarrhea counts suggest that the rotavirus dis-
ease peaks were reduced in magnitude after vaccine introduction.
Given the shifting of the peak and the total diarrhea counts, it is
possible that vaccine use had already impacted the 2013 season
(as had been noted also in Zanzibar, Tanzania [1]), and a transient
‘‘rebound” (less of a reduction) may have occurred in 2014. The
data indicate that the rotavirus burden was lowered further in
2015 and 2016. In 2016, a reduction likely occurred in non-
rotavirus diarrheal hospitalizations as well; the cholera outbreak
that occurred in part of the catchment area led to responses
throughout the region (e.g., chlorination of water sources, health
education) and may have contributed to this result. A limitation
is that data were available from only 2 prevaccine years.
The data from Mbeya Referral Hospital are less straightforward
because of large variations in tally results from the prevaccine
years. Although counts were lower in successive prevaccine years,
2013 counts were higher than 2012 and the same as 2011 (and
among children aged 1 year, 2013 was similar to the high in
2009); we therefore used an additional, conservative comparison
period of 2011–2013 for analysis. The markedly low numbers in
2012 stand out and we could not conclusively determine if there
was a hospital change that could have contributed to this appear-
ance or if this was an accurate reflection of diarrhea burden. Using
the admission diagnosis for tallies instead of discharge diagnosis
for 2011 and 2012 did not yield a different interpretation; we
did identify some irregularities in age recording in 2012 (i.e., a
Please cite this article in press as: Lyamuya F et al. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rota-
virus vaccine introduction. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2017.11.051
7
few weeks with both relatively more children recorded as only
age ‘‘1 year” [without recording of months, such as 1 year 3
months, which would provide more reassurance that nurses ascer-
tained an accurate age] and few recorded as age less than one year,
but not frequently enough to conclude the 2012 data should be
excluded (data not shown). While we are aware from these and
other hospitals that a child’s age in registers can sometimes be
inaccurate because only the year of birth is available, we have no
information on the frequency of such errors and a real impact in
our results would only occur if the rates of errors were different
in prevaccine vs post vaccine period. At Mbeya Referral Hospital,
the data suggest a possible biennial pattern of rotavirus disease
post-introduction, and perhaps even during the prevaccine period
2009–2012 based on the peaks of diarrheal illness during that
period.
There are no clear reasons why the findings at the third hospital
were different from the other two. There was no specific
information that referral practices from the Mbalizi area to Mbeya
Referral for diarrhea had substantially changed over the years
included in this report (i.e., as a reason that 2012 was the highest
year at Mbalizi but low at Mbeya Referral) and the hospitals were a
far distance apart. We have no information to suggest that there
was lower rotavirus vaccine coverage in this area.
The ideal goal would be to have the severe rotavirus burden
reasonably measured before and after vaccine introduction to be
able to quantitate the change in the true outcome that the vaccine
addresses. Examining trends in overall diarrheal hospitalizations
can be attempted when rotavirus-specific data are not available,
as was done here at these particular hospitals and in others in
the African region [8–12], in part because this ‘‘syndromic”-type
disease reduction can resonate more clearly with policy makers
on the value of an intervention. However, there are inherent limi-
tations in ecologic analyses with this non-specific outcome, partic-
ularly in resource-limited settings that have a high burden of
diarrheal illness from pathogens other than rotavirus. It could be
anticipated that the total number of hospitalizations for diarrheal
illness due to specific pathogens other than rotavirus could vary
substantially year by year; analyses of ‘‘total diarrhea” can be made
more specific for the real outcome of interest (rotavirus burden) if
there is a distinct seasonality to rotavirus vs non-rotavirus
diarrheal disease, but such seasonality is not clear for Tanzania.
Diarrhea can also be a component of illnesses caused by a non-
enteric pathogens. In these hospitals, diarrhea was often listed as
the initial or final diagnosis along with malaria (with either term,
malaria or diarrhea, listed first vs second), as has been found else-
where [13,14]. Many such children would not have had malaria
testing and among those that did, a malaria diagnosis may not have
been corrected if the test result was negative. Hence, having
malaria included in the discharge diagnosis for the presumably
febrile diarrheal illness was not specific enough to exclude in our
tally counts or analyze separately. Finally, one can also understand
that some hospitals may have more consistency in illness designa-
tion in ward registers than others.
There are challenges in using ward registers to ascertain
possible impact of rotavirus vaccine introduction on trends in
hospitalizations for treatment of all diarrheal illness. We believe
the data were quite compelling from one of the three hospitals
examined, and moderately so from a second, in supporting disease
burden reductions following implementation of rotavirus vaccine
for all infants in Tanzania.
Disclaimer
The findings and conclusions of in this report are those of the
authors and do not necessarily represent the official position of
8 F. Lyamuya et al. / Vaccine xxx (2018) xxx–xxx
the Centers for Disease Control and Prevention, nor the World
Health Organization.
Funding
This work was supported by the U.S. Agency for International
Development, the U.S. Centers for Disease Control and Prevention,
and the World Health Organization.
Acknowledgements
We are grateful for the support provided by Drs. Angela Shen
and Raz Stevenson (U.S. Agency for International Development,
USAID). We acknowledge the efforts of the many nurses who main-
tained the hospital registers over the years, Mr. Upendo Kusiluka
(Mbalizi Hospital) who maintained and reviewed hospital
statistics, and the additional hospital staff who assisted with and
supported rotavirus surveillance.
Appendix A. Supplementary material
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.vaccine.2017.11.
051.
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